Effect of Yoga on the Autonomic Nervous System: Clinical Implications in the Management of Atrial Fibrillation
Maheswari Murugesan* and Ann Gill Taylor
School of Nursing, University of Virginia, USA
Submission: September 20, 2017; Published: September 21, 2017
*Corresponding author: Maheswari Murugesan, Department of Cardiology, University of Virginia, USA, Email: firstname.lastname@example.org
How to cite this article: Maheswari M, Ann G T. Effect of Yoga on the Autonomic Nervous System: Clinical Implications in the Management of Atrial Fibrillation. J Yoga & Physio. 2017; 3(1) : 555602. DOI:10.19080/JYP.2017.03.555602
Atrial fibrillation (AF) affects about 1.5% of the U.S. population, especially aging persons, resulting in substantial morbidity and mortality. Although radiofrequency catheter ablation is the accepted treatment for AF, failure of this therapy is common. Given that the onset of AF is preceded by a primary increase in the sympathetic drive followed by marked modulation towards vagal pre-dominance, it is likely that stress precipitates and exacerbates AF. The authors searched the databases of Ovid MEDLINE, Pub Med, APA PsycNET, Alt Health Watch via EBSCO host, and CINAHL to evaluate the effects of yoga as a complementary health approach on the autonomic nervous system and how this mind-body modality, if added to conventional treatment, might contribute importantly to reducing or eliminating stress as a trigger for AF. Articles written in English and published in peer-reviewed journals between 2003 and 2017, reporting on research of yoga on autonomic nervous system, were identified. Twenty articles met the inclusion criteria, revealing that yoga resulted in a significant shift in autonomic balance towards vagal dominance; reduction in heart rate and blood pressure; reduction in indices of ventricular repolarization dispersion in patients with ventricular arrhythmias; significant reduction in stress, anger, depression, and anxiety; and improvements in neuroendocrine release, emotional processing, and social binding. Given these literature review findings, the authors provide an integrative overview of biological mechanisms and substrates that mediate AF, which can be targets for future research evaluating how the practice of selected styles of yoga can mitigate the onset of AF.
Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is seen in approximately 1.5% of the U.S. population  and results in substantial morbidity and mortality . One of the largest U.S. epidemiological studies, the Framingham Heart Study, predicted that AF prevalence doubles with each advancing decade of age, from 0.5% at age 50-59 years to almost 9% at age 80-89 years, independent of the increasing prevalence of known predisposing conditions . Although medical treatment involving radiofrequency catheter ablation has become the well-accepted management strategy for AF  failure of this therapy is common, with only two-thirds or less of the patients treated remaining free of AF on long-term follow- up . Early recurrence of atrial tachyarrhythmia, usually defined as arrhythmia recurrence within the first 3 months following ablation, is frequently associated with late recurrence of atrial tachyarrhythmia [4,5]. Acute myocardial injury and the subsequent inflammatory response, as well as modifications of the cardiac autonomic nervous system, provide an early and potentially reversible pro-arrhythmic substrate because of altered atrial myocardial conduction and refractoriness . Research has shown that psychological stressors and imbalance in the autonomic nervous system (ANS) are the most common triggers for paroxysmal AF [6,7]. The mind-body therapy yoga has been shown to reduce stress and maintain autonomic nervous system balance : hence, use of complementary health approaches such as yoga, which are low-cost interventions, might contribute importantly to reducing stress, help individuals maintain balance in the ANS, and thereby prevent recurrence of AF. In this article, the authors provide an overview of AF, the effects of yoga on lessening stress and maintaining ANS balance, and suggest through a psychoneuroimmunological framework the possible mechanisms by which the practice of yoga could mitigate AF episodes and symptoms.
Cumulative lifetime risk estimates reveal that AF is primarily a disease of aging. In U.S. and European community-based cohort studies, the estimated lifetime risk of AF is 22% to 26% in men and 22% to 23% in women by age 80 years . The effects of heart failure, valvular disease, myocardial infarction, and ischemic stroke on AF are substantial. Heart failure increases the risk of AF by a 4.5-fold in men and a 5.9-fold in women. Valvular heart disease increases the risk of AF by a 1.8-fold in men and a 3.4- fold increase in women, with myocardial infarction significantly increasing the risk of AF by 40% in men . Likewise, AF is a potent risk factor for ischemic stroke, increasing the risk of stroke 5-fold, thus leading to about 15% of all strokes nationally .
The most common AF symptoms include palpitations, shortness of breath, fatigue, dizziness, and anxiety. In a study of 100 randomly selected patients with AF, 88% reported palpitations on exertion, 86% reported palpitations at rest, 70% reported shortness of breath on exertion, 87% reported reduced physical ability, and 59% reported anxiety . Adults with major depression, anxiety, or somatization disorder generally have an associated increase in the severity of their AF symptoms .
AF contributes to increased morbidity in the elderly by adversely affecting their quality of life (QOL) and by deterioration in myocardial function, increasing susceptibility to heart failure, stroke, hospitalization, and mortality . Evaluation of QOL in a group of 264 female patients with AF enrolled in the Canadian Trial of Atrial Fibrillation (N = 403) showed that women had significantly more impaired QOL than men, specifically related to physical rather than emotional functioning . In another study, outpatients with documented AF (N = 152) reported substantially poorer QOL than healthy controls . Three of the four well-known randomized controlled trials (STAF, PIAF, RACE) comparing rate versus rhythm control demonstrated a greater improvement in QOL in patients receiving rate control  than those in the rhythm control group. However, the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial revealed a similar improvement in QOL for both rate and rhythm control groups .
A national survey estimated that direct medical costs were 73% higher in patients with AF compared with matched control subjects, representing a net incremental cost of $8705 per patient per year and a national incremental cost between $6 and $26 billion . Retrospective analyses of three federally funded U.S. databases using 2001 data  found that approximately 2,34,000 hospital outpatient department visits, 2,76,000 emergency room visits, 3,50,000 hospitalizations, and 5 million office visits were attributable annually to AF. The total annual medical cost for the treatment of AF in the inpatient, emergency department, and hospital outpatient settings estimated at $6.65 billion is likely an underestimate as costs for long-term anticoagulation, stroke prevention, inpatient drugs, and hospital-based physician services were not included . Patients with AF enrolled in the Fibrillation Registry Assessing Costs, Therapies, Adverse events, and Lifestyle (FRACTAL) study who were managed with cardioversion and pharmacotherapy incurred AF and other cardiovascular-related health care costs of $4000 to $5000 per year . Among patients with recurrent AF, the frequency of recurrence was strongly associated with higher resource use, with each recurrence increasing annual costs by an average of $1600 . The cost-effectiveness of catheter ablation is difficult to determine because of differences in the experience levels of centers treating these patients, use of technology, and rates of reimbursement, each of which affects cost calculations . Researchers evaluating the cost- effectiveness of AF ablation compared with rhythm control or anti arrhythmic agents have shown that ablation treatment results in improved quality-adjusted life expectancy, although at a higher cost [18,19].
Researchers have shown that psychological stressors and imbalance in the autonomic nervous system are the most common triggers for paroxysmal AF [6,7]. Acute life stressors affect the development and spontaneous conversion of AF and are thought to be mediated by the sympathetic nervous system. This hypothesis is supported by increased circulating catecholamine following an acute life stress and by observation that beta-adrenergic blockade prevents abnormal heart rhythm disturbances triggered by acute life stress . In a study of 100 randomly selected patients with idiopathic paroxysmal atrial fibrillation, 54% reported psychological stress as the most common triggering factor for AF . In another study of 116 patients with AF without an obvious cause, acute life stress significantly affected the development and spontaneous conversion of AF .
The autonomic innervations to the heart from the brain, the spinal cord (extrinsic system) and the ganglion plexi of the heart itself comprise the local ANS (intrinsic system) . This intrinsic cardiac ANS of the heart and the pericardium serves as more than a relay station for the intrinsic projections of the vagal-sympathetic system from the brain and spinal cord to the heart. Supporting this theory is the fact that ablation of the major ganglion plexi at the pulmonary vein atrial entrances either eliminates or markedly diminishes AF inducibility. Also, this intrinsic cardiac autonomic system can act independently to modulate numerous cardiac functions, including automaticity, contractility, and conduction .
In addition to the sympathetic component of the ANS, the parasympathetic component has been shown to play a role in AF . Amar et al.  showed that the onset of AF was preceded by a primary increase in the sympathetic drive followed by marked modulation toward vagal pre-dominance. The physiologic studies by Patterson et al.  further indicate that sympathetic stimulation plays an important modulatory role in the emergence of focal drivers for AF in the presence of an increased vagal tone. The ANS is involved in the genesis of both AF triggers (i.e., ectopic foci that result from interaction between vagal and sympathetic stimulation) and the creation of a more established AF substrate that is needed for the maintenance of AF and is enhanced in the presence of structural heart disease . It has been shown that the abnormal electrical conduction within the pulmonary veins could be sustained only in the presence of isoproterenol or acetylcholine, indicating that sympathomimetic or cholinergic stimulation appears to be necessary to promote the development of sustained focal activity in the pulmonary veins .
Heart rate variability (HRV), the variance between the R-R intervals or complete cardiac cycle on the electrocardiogram, can be used to assess the balance between the sympathetic and parasympathetic branches of the ANS . Efferent sympathetic and parasympathetic activity is integrated in and with the activity occurring in the heart's intrinsic nervous system. Thus, HRV is considered a measure of neurocardiac function that reflects heart-brain interactions and ANS dynamics . HRV is assessed with various analytical approaches, although the most commonly used are frequency domain (power spectral density) analysis and time domain analysis . The European Society of Cardiology and the North American Society of Pacing and Electrophysiology Task Force Report on HRV divided heart rhythm oscillations into 4 primary frequency bands: high- frequency (HF), low-frequency (LF), very-low-frequency (VLF), and ultra-low-frequency (ULF) . It is often assumed that a low LF:HF ratio reflects greater parasympathetic activity relative to sympathetic activity . In contrast, a high LF:HF ratio may indicate higher sympathetic activity relative to parasympathetic activity as can be observed when people engage in meeting a challenge that requires effort and increased sympathetic activation. Alternatively, it can indicate increased parasympathetic activity as it occurs during slow breathing. Time domain indices quantify the amount of variance in the inter-beat-intervals using statistical measures. The three most important and commonly reported time domain measures are the standard deviation of normal-to-normal (SDNN), the SDNN index, and the root mean square of successive differences (RMSSD) . The modulation of vagal tone helps maintain the dynamic autonomic regulation important for cardiovascular health. Reduced parasympathetic (high frequency) activity has been found in cardiac pathologies and in patients under stress or suffering from panic, anxiety, or worry .
Yoga, an ancient discipline from India, is a mind-body exercise in which both physical and mental disciplines are brought together to achieve peacefulness of mind and body, resulting in a relaxed state that is useful in managing stress and anxiety. To date, two studies have assessed the impact of yoga on AF. One, a proof-of-concept study , revealed that 60-minute Iyengar yoga sessions at least twice a week for 3 months improved symptoms, arrhythmia burden, heart rate, blood pressure, anxiety and depression scores, and several domains of QOL in adults with paroxysmal AF. A second study  using mediyoga as the intervention, showed that this style of yoga might potentially lower blood pressure, lower heart rate in patients with paroxysmal AF, and improve QOL compared to a control group.
Given the potential positive impact of yoga on decreasing AF episodes and symptoms as shown in Table 1, the authors conducted an extensive computerized search of diverse databases (Ovid MEDLINE, Pub Med, APA PsycNET, Alt Health Watch via EBSCO host, CINAHL), using key terms of heart rate variability and autonomic nervous system, to assess the effect of yoga on the ANS. These computerized searches yielded 230 studies (Ovid MEDLINE = 25, Pub Med = 31, APA PsycNET = 16, Alt Health Watch = 153, CINAHL = 5), which were then reviewed for eligibility. Inclusion criteria were English language articles reporting on studies that (a) enrolled subjects 18 years and older and (b) were published between 2003 and 2017 in peer- reviewed scientific journals.
The 20 articles that met the inclusion criteria are shown in Table 2. Seventeen were interventional studies with 14 of these using random sampling; 3 used non-randomized sampling techniques. One of the studies included a discussion of the effect of yoga on the parasympathetic and GABA systems  and the other study reviewed the health impacts of yoga and pranayama . The review also identified two relevant articles that provided additional information on the impact of yoga on the ANS. One of the articles, provided a review of the health impacts of yoga and pranayama  and the second proposed a neurophysiologic model to clarify the mechanisms by which SudharshanKriya yogic breathing balance the autonomic nervous system activity .
The participants in all 17 interventional studies were adults aged 18 years or older. Three studies included only male participants, with the rationale for excluding females being the tendency in variation of the autonomic variables with the phases of the menstrual cycle in females. However, Markil et al.  included 15 women in their study, completing the study during the follicular phase of the menstrual cycle given that the luteal phase causes increase in sympathetic activity. One study did not mention the sex of the participants. Of the 17 interventional studies, 8 were completed in India, 5 within the United States, 1 in each completed in Australia, Germany, Brazil, and Nepal. Women and ethnic minorities were under represented in these studies. Most of the studies except for Dabhade et al.  excluded patients with arrhythmias and those on any medications such as beta-blockers and anti-arrhythmic medications that have significant effect on heart rate and rhythm.
The studies reviewed showed that participation in a yoga intervention resulted in a significant shift in autonomic balance towards vagal dominance; a reduction in heart rate and systolic, diastolic, and mean blood pressure; a reduction in the indices of ventricular repolarization dispersion (QTd, JTd) in patients with ventricular arrhythmias; significant reduction in stress, anger, depression, anxiety, and neurotic symptoms; and improvements in neuroendocrine release, emotional processing, and social binding. Both time and frequency domain indices of heart rate variability showed significant changes towards parasympathetic modulation. Bidwell, et al.  found that yoga training for females with mild to moderate asthma decreased parasympathetic activity and increased sympathetic modulation as assessed by isometric forearm exercise. Yoga not only causes increased parasympathetic tone but when needed decreases the highly active parasympathetic nervous system to maintain a balanced autonomic nervous system activity.
Right nostril yoga breathing can increase sympathetic tone and cardiac sympathetic activity, resulting in increased blood pressure and heart rate. Left nostril yoga breathing can decrease systolic and mean blood pressure while alternate nostril breathing can decrease both systolic and diastolic blood pressure . Slow breathing exercises can improve sympathetic and parasympathetic reactivity . Slow pace
Bhastrikapranayama exercise has shown a strong tendency towards improving function of the ANS through enhanced activation of the parasympathetic system . Yoga practice of cyclic meditation during the day appears to shift sympatho- vagal balance in favor of parasympathetic dominance during sleep on the following night which promotes improved quality of sleep . Four months of respiratory training in Bhastrika pranayama increased respiratory function and improved cardiac parasympathetic modulation in a group of healthy elderly subjects . The changes during Dhyana (meditation)  and guided relaxation  resulted in reduced activity of the sympathetic nervous system showing a shift in autonomic balance towards vagal dominance. Laughter yoga therapy for individuals awaiting heart transplant showed improvement in vigor-activity, friendliness, and long-term anxiety. It also improved HRV measures within or close to normal ranges from being low at baseline perhaps related to reduced vagal stimulation . Integrated yoga practice reduced perceived stress and improved adaptive autonomic response to stress in healthy pregnant women .
The styles of yoga reported on in the research reviewed include Hatha yoga, viniyoga, Ishayoga, Iyengar yoga, laughter yoga, integrated yoga, yoga nidra relaxation, meditation (cancalata, ekagrata, dharana, dhyana), pranayama (Bhastrika, Kapalbhati, Anilom-vilom, Bhramari, Udgit), cyclic meditation, guided relaxation and yoga breathing practices. Yoga postures, breathing exercises, pranayama, and meditation reportedly led to a significant shift in autonomic balance towards vagal dominance, which can prevent tachycardia, an important goal in the management of AF.
Only 4 studies mentioned the number of participants who completed the studies, with attrition rates ranging from 3.3% to 54.06%. The primary reasons for participants not completing a study were drop outs, irregular attendance at intervention sessions, and relocation following study enrollment. Higher attrition occurred in 'in-person' mindfulness therapy groups (27.3%) compared to the 'online' mindfulness meditation groups (3.8%) , giving rise to the need to consider the format and location of yoga interventions. Also, the studies reviewed did not provide an explicit theoretical or conceptual framework to explain the basis for the yoga interventions used with the study population.
To address the deficit in the literature regarding theoretical or conceptual frameworks in the studies reviewed, the authors identified a psychoneuroimmunological framework adapted from McCain et al.
shown in Figure 1 to depict the electrical, mechanical, and structural changes in the heart that lead to a stress-related imbalance in the ANS resulting in AF. Yoga interventions can potentially foster the electrical stability of the heart by maintaining ANS balance and lessening AF episodes, AF symptoms (palpitations, shortness of breath, dizziness, and fatigue), stress, depression, and anxiety, thus improving the participants’ health-related QOL. Modulating factors such as stress can cause imbalance in the ANS, which, in turn, can lead to AF. Persistent AF causes inflammation and fibrosis of the atria, resulting in a fixed substrate for re-entry and consequent sustained episodes of AF , making treatment options to break this re-entrant cycle challenging. Triggers for atrial fibrosis include the activation of the renin-angiotensin- aldosterone system, inflammation, and oxidative stress . The combination of normal and diseased atrial fibers in conjunction with local fibrosis results in spatial dispersion of atrial refractoriness and causes localized conduction abnormalities, including intra-atrial conduction block and slow conduction
 . Thus, the interplay of stress (psycho), imbalance in the ANS (neuro), activation of the renin-angiotensin-aldosterone system, inflammation and oxidative stress resulting in atrial fibrosis (immuno) triggers AF and creates a substrate for persistent AF. Mind-body approaches use the concept of body and self-awareness to promote rechanneling of energy within the body thereby maintaining an internal balance. This mind- body balance can further reduce  psychological stressors that are important modulating factors in AF and modulate the ANS to parasympathetic dominance in maintaining a stable myocardium, thereby preventing arrhythmias.
Even though the time span of the yoga interventions reported in the studies reviewed ranged from a few minutes to months, all the studies demonstrated some beneficial effect in maintaining nervous system balance and significant impact on selected physiological and psychological factors, thereby improving the participants' overall QOL. Given its impact on modulating autonomic system balance and reducing psychological stress, selected styles of yoga might be considered as cost-effective complementary health approaches in managing AF episodes and symptoms. Further rigorous study is warranted to clarify further the specific mechanisms involved in the use of yoga in patients diagnosed with AF.